Provider Demographics
NPI:1558509786
Name:BONNEY LAKE PHYSICAL THERAPY AND HAND REHAB, PLLC
Entity Type:Organization
Organization Name:BONNEY LAKE PHYSICAL THERAPY AND HAND REHAB, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:EGBERT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:253-862-2575
Mailing Address - Street 1:20910 STATE ROUTE 410 E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-6302
Mailing Address - Country:US
Mailing Address - Phone:253-862-2575
Mailing Address - Fax:253-862-2675
Practice Address - Street 1:20910 STATE ROUTE 410 E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-6302
Practice Address - Country:US
Practice Address - Phone:253-862-2575
Practice Address - Fax:253-862-2675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-26
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT5418225100000X, 2251X0800X
WAOT2499225XH1200X, 225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA246114OtherLABOR AND INDUSTRIES PT/ MICHAEL
WA7421EGOtherBLUE SHIELD MICHAEL PT
WAG8879641OtherMEDICARE PTAN BRANDY
WA246111OtherLABOR AND INDUSTRIES OT/ BRANDY
WA264113OtherLABOR AND INDUSTRIES
WA6598CAOtherBLUE SHILD BRANDY OT
WA7146897Medicaid
WAG8879917OtherINDIVIDUAL PTAN MICHCAEL
WA8368854OtherMEDICAID OCCUPATIONAL THERAPY
WA8543712OtherMEDICAID PHYSICAL THERAPY
WAG8879641OtherMEDICARE PTAN BRANDY